The boat slowed to a stop. As the eldest son, Rajiv was given the honor of scattering the ashes, but I wouldn’t have been able to do so anyway; by then I was feeling horribly seasick. On the deck, while the priest chanted, his bald pate glistening in the heat, Rajiv placed the wicker basket on a metal hook at the end of a long stick. Then, without ceremony or words—apart from the inscrutable Sanskrit syllables spitting out from the priest’s lips—he leaned over the side of the boat and lowered the basket into the water. It had a metal weight to help it sink. I watched it submerge like a head, ghostlike, its contents exploding into a murky cloud in the greenish water. The priest told us to clasp our hands together in prayer. No one said anything as he violently chanted. Then, when he was done, a crew member retrieved the basket with some rope and lifted it back onto the boat. We turned around to head back to shore.
My father rode in the car with me on the way home. We were both tired, and my stomach was just beginning to settle. I put on Beethoven’s Piano Sonata no. 8, the Pathétique. I looked over at my father. He was staring ahead quietly, listening to the music. He rolled down the window, and a hot wind passed over us. He said nothing for a while; there were only the shrieks and wails of passing cars. Then he said, “We spent our whole life together. I miss her all the time.”
14
Compensatory Pause
Satisfaction cannot be stored.
—Peter Sterling, neurobiologist
In 1990, Dean Ornish, a cardiologist at the University of California at San Francisco, and his colleagues published the Lifestyle Heart Trial in the British journal The Lancet. In the study, forty-eight patients with moderate-to-severe coronary artery disease were randomly assigned to usual care or an “intensive lifestyle” that included a low-fat vegetarian diet, an hour of daily walking, group psychosocial support, and stress management. After a year, patients in the lifestyle group had a nearly 5 percent reduction in coronary plaque. After five years, the reduction was about 8 percent. Patients who adhered most closely to the program derived the most benefits in an almost dose-dependent relationship. Patients in the group receiving usual care, on the other hand, had an average 5 percent more coronary obstruction after one year and 28 percent after five years. They also had roughly double the rate of cardiac events, including heart attacks, coronary angioplasty, coronary artery bypass surgery, and cardiac-related deaths.
Ornish’s study was roundly criticized. It tested a small cohort, reviewers said, hardly representative of the general population. Only half the patients who were invited actually participated, suggesting possible selection bias. Also, virtually none of the patients were on statins or other cholesterol-lowering drugs, so the effect of intensive lifestyle modification on modern, well-treated heart patients was anyone’s guess. Moreover, a study published in 2013 in The New England Journal of Medicine showed that patients who consume a Mediterranean diet rich in olive oil, fruits and vegetables, fish, and nuts had a roughly 30 percent lower risk of cardiac events, including heart attacks and death, than patients advised to follow a low-fat diet, albeit one less extreme than Ornish’s.
Nevertheless, Ornish believed in his results and scaled up his program, eventually offering it at twenty-five hospitals and clinics across the country. He persuaded Medicare to pay for it as a kind of “intensive cardiac rehabilitation.” The Ornish plan today consists of two four-hour sessions per week for nine weeks, each comprising an hour-long nutrition class, an hour of exercise, an hour of group support facilitated by a social worker, and an hour of yoga and meditation.
I’d heard Ornish speak about the benefits of his program, so one Friday afternoon in early fall I drove out to the Chambers Center for Well Being in Morristown, New Jersey, the closest Ornish center to where I live, to learn more. I went for a selfish reason. I’d recently learned the results of my CT scan.
When Dr. Trost showed me my coronary blockages, I can’t say I was surprised. I’d worried so much about heart disease my whole life that the result seemed almost fated. The disease was still relatively mild, but I knew that most ruptures of coronary plaque—and therefore most heart attacks—occur at places of mild, not severe, narrowing. Mild plaque tends to be softer, thinner, more fat-laden, and possibly more prone to rupture and thrombosis than more advanced plaque.* So I found myself in a clinical catch-22, with a disease too small to fix yet too large to ignore. Why had it developed? Was it the few cigarettes I’d smoked in college? Too many pastries and marital spats? Or was the disease programmed into me? Whatever the reason, my future suddenly seemed intolerably unpredictable. I had a peculiar feeling that I wanted to speed up my life to witness the important moments before I ran out of time.
EKG showing a premature ventricular contraction
For years, ever since medical school, I’ve had premature ventricular contractions, a mostly benign condition in which my heart flutters or does a sort of flip-flop when an extra, unexpected beat comes in. Most PVCs are followed by a “compensatory pause,” when the next heartbeat is delayed so the heart can get back in step with its normal rhythm. During the compensatory pause, the ventricles fill with blood for a bit longer than usual, so the first beat after a premature one is unusually strong, a thud in the chest to announce the heart’s rhythm has gone back to the way it was. As I lay in my den after my scan, listening to the crickets outside, it occurred to me that my scan was like a PVC, an interruption of the normal sequence of things. Was I going to let things go back to the way they were? Or was I going to do a reset?
Over the following days, I underwent more tests. An echocardiogram showed that my heart’s chambers and valves were functioning normally. A carotid ultrasound revealed no plaque in the arteries that feed the brain. However, a blood test did show that my level of lipoprotein(a), a cholesterol-carrying molecule, was elevated. A high serum concentration of lipo-protein(a) is associated with more than double the normal risk of developing coronary artery disease or stroke.
Lipoprotein(a) could partially explain the extraordinarily high rates of heart disease and cardiovascular death among South Asians, but there are other factors. South Asians seem to have smaller coronary arteries than other ethnic groups, which may result in more turbulent blood flow and wall stress that can initiate atherosclerosis. South Asian blood may also contain smaller and denser cholesterol particles that are more prone to causing arterial hardening. The adoption of a “Western” lifestyle—high calories, low exercise—hasn’t helped either, possibly activating so-called thrifty genes that create abdominal fat, thus increasing the risk of insulin resistance and diabetes. (These genes might have been advantageous in times of famine, but they are a problem in a world of abundance.) Social and cultural factors undoubtedly play a role, too. This was certainly true of my mother. The culture in which she was brought up discouraged adults from taking time for themselves, away from the responsibilities of job, home, and children, to exercise. Moreover, like many of her Indian friends, my mother believed in fate, that her future—and future health—were preordained. Saddled by this fatalistic philosophy, she never believed that one could change the natural course of one’s life.
But I did not want my CT scan to be my fate. I wanted to make changes to try to stabilize—or possibly even reverse—the damage. But what sorts of changes were needed? I was already leading a pretty healthy life. I was taking a cholesterol-lowering statin prophylactically. The changes, I realized, were going to have to be more fundamental.
I called my friend Anand, a television producer and a yogi, who suggested getting together one evening after work at the Hindu temple in Flushing. It was a warm midsummer evening when we met. The temple is in a middle-class neighborhood of single-family homes partitioned by rusty chain-link fences. A sign out front reminded patrons, “Do not break coconut here.” When I arrived, a prayer ceremony was just ending. A man clad in a white dhoti was clanging a bell and fervently chanting, “Shanti, shanti, shanti …” I spotted Anand, a paunchy, middle-aged fellow, wearing beige kurta pajamas and
with a streak of red powder on his forehead. Head bowed, he moved purposefully from one garlanded statue to the next, kneeling at each to murmur a few words. When he was finished, he came over and shook my hand. Then we went downstairs to the canteen, where we ordered dosas and sweet lassi and sat down at a cafeteria-style table to wait for our food.
I felt as if I should explain why I had called him, but Anand seemed to require no explanation. He sat contentedly, taking in the busy room. After some polite chitchat, I told him about my scan. Brow furrowed, he listened carefully in the manner of a psychoanalyst.
“I have always found you take things very seriously,” Anand finally said. In his mind, my scan results no doubt were related to this. “Learn to get out of your mind.”
I laughed. “And how does one do that?”
His face turned serious. “Yoga, meditation, a walk in the park, whatever works. When you are doing it, you think it is a waste of time, but it is the most valuable time because it is helping you manage the whole day.”
I’d tried yoga a few times. After Sonia and I were married, we’d ventured down to a drab studio in Tribeca, where a mala-necklaced old woman made us stand in painful poses while we focused on a spot on a pitted wall. I did feel more relaxed afterward (probably acute respiratory alkalosis brought on by deep breathing, I’d hypothesized), but I hadn’t kept up with the practice.
Anand advised returning to it. “Look at this scan as a blessing,” he said encouragingly. “It will help you find ways to become more composed. Your mind, your thoughts, are not your owner, but they are behaving as your owner. Go beyond mind. That is the only place you are truly free.”
•
And so I found myself in Morristown, New Jersey. The Ornish facility was in a large office complex just off a densely wooded road. The giant oak trees were already dropping their leaves into colorful piles. Carole, the nurse practitioner who runs the program, met me at the front desk when I arrived. “We’ve had quite a few young Indian men call us,” she’d told me when we spoke on the phone.
The sessions were over for the day, so Carole gave me a tour of the facility: the kitchen, with its polished stovetops, where participants spend an hour together having a vegetarian lunch; the gym, supervised by two nurse practitioners and an exercise physiologist, where a few stalwarts were still running on treadmills; and the stress management room, where chairs were arranged in a circle and yoga mats were still on the floor. Carole told me her father was seventy when he was diagnosed with heart disease. He’d been having pains in his shoulder, and though a stress test was normal, a coronary angiogram revealed triple-vessel disease that was so advanced, surgery or angioplasty was no longer an option. “He was living on threads,” she said. With no treatment alternatives, her father tried the Ornish program. He followed it for two months before dying suddenly of an arrhythmia. Despite this morbid introduction, Carole had been working in Ornish-style preventive cardiology ever since.
In her office, Carole showed me angiograms of program participants whose coronary disease had regressed. “When people talk about the Ornish program, they usually talk about the diet,” she said. “But the social support and stress management are probably the most important pieces.” Patients were often reluctant to participate in group therapy, she said. “Some ask for a waiver. They don’t want to open up to strangers. But it almost always ends up being their favorite part.”
Ornish himself puts a great premium on the psychosocial piece of his program. He has pointed out, for example, that some patients in his original control group adopted diet and exercise plans that were almost as intense as those of the intervention group. However, their heart disease still progressed; diet and exercise alone weren’t enough to facilitate coronary plaque regression. At both one- and five-year follow-ups, stress management was more strongly correlated with reversal of coronary artery disease than exercise. “The need for connection and community often goes unfulfilled in our culture,” Ornish said in a 2015 interview. “We know that these things affect the quality of our lives, but they also affect our survival to a much larger degree than most people realize.”
Many studies have suggested that Ornish is probably right. In one example, patients who were depressed after a heart attack were four times as likely to die within six months as those who were not, irrespective of usual Framingham risk factors like high cholesterol, hypertension, obesity, and smoking. In another study, menopausal women with no history of cardiovascular disease who expressed more hopelessness on a psychological questionnaire had more carotid artery thickening and an older vascular age than matched patients who felt good about their lives.* No doubt many of these studies are small, and of course correlation does not prove causation; it is certainly possible that stress leads to unhealthy habits—poor nutrition, less physical activity, more smoking—and this is the real reason for the increased cardiovascular risk. But as with the association of smoking with lung cancer, when so many studies show the same thing and there are mechanisms to explain a causal relationship, it seems perverse to deny that one probably exists. What Ornish and others have concluded is fully consistent with what I have learned in my two decades in medicine: that the emotional heart affects its biological counterpart in multiple mysterious ways.
Carole told me she uses “trackers” to see how well patients follow the program on the days they do not come to the center. There are trackers for diet and exercise, of course, but also ones for love and support. Patients are asked to rate “How connected am I?” on a simple numerical scale. Those who do more than one hour of stress management daily have the greatest improvement in coronary blood flow. “We run our lives at such a frenetic pace,” Carole said. “Our sympathetic nervous systems are on overdrive. But how we react to the stress is under our control.”
Unfortunately, I was not going to be able to participate in the Ornish program. Traveling to New Jersey twice a week for nearly three months wasn’t feasible, and abridged courses, Carole sadly informed me, were not yet available. She promised to send me some material so I could get started on my own. “Try to find joy in each day,” she said, walking me to the elevator. “Instead of thinking about the past or worrying about the future, focus on the present.” I told her I would do my best. Then I went down to the parking lot, got into my car, and joined the Friday evening rush toward Long Island.
•
Perhaps more than any other area of medicine, cardiology has been at the forefront of technological innovation and quality improvement over the past fifty years. This golden period has witnessed a barrage of life-prolonging advances, many of them discussed in this book, including implantable pacemakers and defibrillators, coronary angioplasty, coronary bypass surgery, and heart transplantation. Preventive health initiatives, such as smoking cessation and cholesterol and blood pressure reduction, have supplemented these biomedical advances. The result has been a 60 percent drop in cardiovascular mortality since 1968, the year I was born. There are few stories in twentieth-century medicine that have been as uplifting or far-reaching.
For a while it appeared that cancer would replace heart disease as the leading cause of death in the United States, but no more. The rate of decline in cardiovascular mortality has slowed significantly in the past decade. There are many reasons for this. The fall in smoking rates has leveled off. Americans have become more overweight. Diabetes cases are projected to nearly double in the next twenty-five years. But I believe there is another reason, too. Cardiology in its current form might have reached the limits of what it can do to prolong life.
This would have been heresy to pioneers like Walt Lillehei, Andreas Gruentzig, and Michel Mirowski, but today it is hard to refute. The law of diminishing returns applies to every human enterprise, and cardiovascular medicine is no different. For instance, ever since coronary thrombosis was shown to be the cause of most heart attacks, cardiologists have taken it as an article of faith that more rapid treatment of such thromboses improves patient survival. “Time is muscle,” go
es the operative mantra, and the shorter the delay, the better. Yet a study of nearly 100,000 patients published in 2013 in The New England Journal of Medicine found that shorter “door-to-balloon” times—the period from a patient’s hospital presentation to inflation of a balloon to restore coronary blood flow—did not improve in-hospital survival. The median door-to-balloon time dropped to sixty-seven minutes, from eighty-three, in the period studied, but short-term death rates did not change.
There are several plausible explanations for this result. Perhaps heart attack patients who are healthier and at low risk for death are already getting expeditious treatment, and those who are at higher risk are experiencing the most delays. Perhaps the follow-up time in the study was too short, and if we waited a bit longer, a survival benefit would be seen. Or perhaps there is another reason. Mortality after a heart attack has already dropped tenfold, from 30 percent to 3 percent, since Mason Sones invented coronary angiography in 1958. Can the tweaking or speeding up of existing procedures possibly yield any significant additional benefit?
There are other examples of such diminishing returns. In my specialty, heart failure, medications such as beta-blockers and ACE inhibitors have profoundly improved survival since their advent in the mid-1980s. Yet recent studies of newer agents—endothelin blockers, vasopressin antagonists—have shown little benefit. Today patients’ Framingham risk factors, such as hypertension and high cholesterol, are better controlled. It is getting harder to improve on existing successes.
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